Synopsis: Published: 2012-11-05 - Proposed agreement would permit people on Medicare to continue receiving physical and occupational therapy and services at home or in a long-term care facility - Disabled World.

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The potential for thousands of people on Medicare who experience severe and chronic forms of illnesses such as Alzheimer's to continue accessing rehabilitation and additional services under a change agreed upon by the current administration has increased, according to advocates.

The proposed agreement in a national class action suit would permit people on Medicare to continue receiving both physical and occupational therapy and additional skilled services either at home, or in a long-term care facility, with the goal of keeping them stable according to a lawyer for the Center for Medicare Advocacy. In the past, receiving these services has been an issue for some people due to a longstanding Medicare policy that stated people needed to demonstrate improvement in order to continue receiving rehabilitation.

The lead attorney in the case, Mr. Deford stated, "If you have a chronic condition, by definition you are not improving. Our view is that Medicare regulations were intended to allow people to maintain their health status. They don't have to show they are getting any better. The point is to allow them not to get any worse, if possible."

The agreement was filed with Chief Judge Christina Reiss of the District Court of the State of Vermont. The decision is expected to affect tens or even hundreds of thousands of people on Medicare in America. The people who may benefit includes not only those who experience conditions such as Alzheimer's, Parkinson's, chronic lung disease, or Multiple Sclerosis. The agreement will also affects people who are becoming weaker due to advancing age; something that places them at an increased risk of a fall or other issues.

The impact on the Medicare budget remains unclear, partly due to the fact that program rules are not always enforced rigidly. Despite a requirement that people must continue to demonstrate improvement, billing contractors at times defer to the judgment of therapists and doctors. While a person's underlying illness or injury may be worsening, therapy may assist them to maintain their strength and continue to do more self-care and remain more independent. Despite these facts, there is no guarantee the Medicare program will pay.

Deford also stated, "That's what the point of this case is. This will allow them to have access." Advocates say the Medicare program might even break even on a financial basis if people do not have to enter a hospital for their condition. Those who have been repeatedly denied Medicare coverage for rehabilitation services have filed a number of suits in the past.

In court paperwork, Medicare denied that it has imposed an inflexible standard in regards to requiring that people continue to improve in order to receive rehabilitation services. In fact - there is actually no such requirement in law. Medicare stated that additional factors bear on situations, such as a person's particular medical condition and whether treatment is both reasonable and needed. Lawyers for the government called the policy a change in clarification.

Erin Shields Britt, a spokeswoman for the Health and Human Services Department stated, "This settlement clarifies existing Medicare policy. We expect no changes in access to services or costs." Nevertheless, the policy manual for Medicare will be changed to state that coverage of rehabilitation services, "does not turn on the presence or absence of a beneficiary's potential for improvement from the therapy, but rather on the beneficiary's need for skilled care." Deford stated it may be a number of months before the settlement itself is finalized in court and as much as another year before Medicare formally changes its policy.

People might; however, begin to see changes before then. Deford stated, "I'm hoping the new coverage rules will de facto take effect before they are formally revised." The majority of those who will benefit immediately will be the parents of people in the baby boom generation, as well as younger persons with disabilities who are also entitled to Medicare coverage. The changes to Medicare due to this agreement may have the most significant impact for members of the baby boom generation, many of whom are expected to attempt to live independently well into their 80's and 90's.

Medicare coverage for hospitalization include payment for services that are generally available in a hospital such as:

Medications

Bed and board

Medical social services

Supplies and equipment

Use of hospital facilities

Diagnostic or therapeutic items

Nursing services and other related services

Medical or surgical services provided by certain interns and residents

Section 1361 of the Medicare Act, 42 U.S.C. Section 1395x(e) defines, 'hospitals,' to include institutions that provide rehabilitation as well as care for an acute illness. Under this particular section of the Medicare Act, hospitals are defined to include institutions that provide, "therapeutic services for medical diagnosis, treatment and care of injured, disabled, or sick persons, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons."

Medicare claims for inpatient rehabilitation hospital care can be appealed if they meet certain criteria. The criteria include the following:

The care the person receives is in a Medicare certified facility

A coordinated multidisciplinary team provides the rehabilitation program

The person needs a fairly intense, multidisciplinary rehabilitation program

The person's doctor certifies that inpatient hospitalization for rehabilitation is medically necessary

The goal of the person's rehabilitation program is to upgrade their ability to function as independently as possible

Do not pay attention to arbitrary caps placed on coverage by the Professional Review Organization (P.R.O.). Do not, for example, accept any assertions that Medicare coverage is not possible if a person needs less than three hours a day of physical or occupational therapy, or that hospitalization for some conditions such as upper extremity paralysis or below the knee amputations are not covered. The Medicare regulations and statute do not include any such restrictions. An administrative law judge will grant a person coverage if it can be demonstrated that a person needed a multidisciplinary, coordinated rehabilitation program provided by a team of professionals that was not available at a long-term care facility or on an outpatient basis.

A person who needs close medical supervision such as twenty-four hour per day availability of a doctor or a nurse who is trained or experienced in rehabilitation can be helpful in successfully winning a Medicare claim appeal. The person's attending doctor is always the key to receiving Medicare benefits. If at all possible, get a statement from the person's doctor explaining why inpatient hospital rehabilitation is medically necessary and that the rehabilitation program the person needs is not actually available to them through a long-term care facility or on an outpatient basis.

Refuse to be satisfied with a Medicare determination that unreasonably limits coverage. Do not allow the person to go without the medical care they need. Appeal for the benefits the person deserves. It will take time, but the benefits will most likely be won in the end.

A Medicare Rehabilitation "Gotcha": When 100 Days Isn't 100 Dayswww.eldercareteam.com/public/221.cfm

When her mother had a stroke Sandy didn't know the first thing about Medicare defined benefits and "Rehabilitation Days."

A federal standard being phased in - the so-called "75% Rule" - would make it more difficult for a hospital to qualify as an IRF, with the result that more beneficiaries would lose access to this care and, instead, would likely enter SNFs for rehabilitation. Care in these settings is not the same.

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